A multi-country cross-sectional study to assess predictors of daily versus on-demand oral pre-exposure prophylaxis in youth from South Africa, Uganda and Zimbabwe

Introduction Sub-Saharan Africa (SSA) carries the burden of the HIV epidemic, especially among adolescents and young people (AYP). Little is known about pre-exposure prophylaxis (PrEP) uptake and preferences among AYP in SSA. We describe preferences for daily and on-demand PrEP among AYP in South Africa, Uganda and Zimbabwe. Methods A cross-sectional survey was conducted in 2019 among 13- to 24-year olds, capturing socio-demographics, HIV risk behaviours and preferences for daily or on-demand PrEP. Logistic regression models were used to estimate odds ratios, adjusting for site, sex and age. Results and discussion A total of 1330 participants from Cape Town (n = 239), Johannesburg (n = 200), Entebbe (n = 491) and Chitungwiza (n = 400) were enrolled; 673 (51%) were male, and the median age was 19 years (interquartile range 17-22 years). Of 1287 participants expressing a preference, 60% indicated a preference for on-demand PrEP with differences by site (p < 0.001), sex (p < 0.001) and age group (p = 0.003). On-demand PrEP was most preferred in Entebbe (75%), among males (65%) versus females (54%) and in older participants (62% in 18- to 24-year-olds vs. 47% in 13- to 15-year-olds). After adjusting for site, sex and age group, preference for on-demand PrEP decreased as sex frequency over the past month increased (p-trend = 0.004) and varied with the number of partners in the last 6 months, being least popular among those reporting four or more partners (p = 0.02). Participants knowing further in advance that they were likely to have sex were more likely to prefer on-demand PrEP (p-trend = 0.02). Participants having a larger age gap with their most recent partner and participants whose last partner was a transactional sex partner or client were both less likely to prefer on-demand compared to daily PrEP (p = 0.05 and p = 0.09, respectively). Participants who knew their most recent partner was living with HIV or who did not know the HIV status of their most recent partner were less likely to prefer on-demand PrEP (p = 0.05). Conclusions Our data show that AYP in four SSA communities prefer on-demand over daily PrEP options, with differences seen by site, age and sex. PrEP demand creation needs to be reviewed, optimized and tailored to socio-demographic differences and designed in conjunction with AYP.